Objectives: Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients. Design: Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system. Setting: Wishard Health Services senior care and community mental health clinics. Participants: Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics. Results: Patients having serious mental illness had significantly higher rates of medical emergency department visits (p - 0.0027) and significantly longer lengths of medical hospitalizations (p < 0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p < 0.0001). Reported falls (p < 0.0001), diagnoses of substance abuse (p - 0.02), and alcoholism (p - 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care. Conclusions: Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

BACKGROUND:The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research.METHODS:Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the "Indianapolis Discovery Network for Dementia" (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana.RESULTS:The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org ). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD$24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the "IDND consultancy round."CONCLUSION:A local interdisciplinary "think-tank" network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built.

Background: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. Objective: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. Methods: We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). Results: Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. Conclusion: The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.

The Aging Brain Care Medical Home is a primary care-based dementia care program focused on providing collaborative care for dementia and late-life depression. The ABC Medical Home provides a set of services integrated within a community-based primary care practice, and requires a large investment in system redesign. It utilizes collaborative care models that guided the program redesign, and addresses the perceived system-level barriers to adoption of the new models of care. The goal of the program is to identify, evaluate, and manage the biopsychosocial needs of older adults suffering from dementia and/or depression and their family caregivers. Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. The reflective adaptive process was used as a relationship building framework, recognizing primary care practices as complex adaptive systems. This framework allowed for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic and by information technology resources. The target patient population is older adults who receive their primary care from clinical practices affiliated with Wishard Health Services. In order to efficiently deliver the components of the ABC Medical Home, the care team is supported by an array of information technology tools, including a laptop workstation with access to computerized order-entry and electronic medical records; electronic capture of patient outcome data including functional, behavioral, psychological, and cognitive symptoms; a web-based tracking system to support care coordination; and a telephone/email system to communicate with caregivers, patients and providers. The technology provides the flexibility to deliver care and access needed data in other clinical settings with the health care system, in facilities outside the system and in patient homes. We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems.

Despite numerous quality improvement efforts, best practice guidelines, and clinical and basic research activities over the past three decades, dementia is still underdiagnosed and undertreated, especially among minorities. Furthermore, even among those receiving optimal care, only a small proportion participate in clinical trials. The Institute of Medicine has recommended the need for system thinking and integrated, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. It is hypothesized that an effective collaboration would improve diagnosis and treatment of the dementia patient, as well as increase participation in research. A local and diverse network of dementia researchers, clinical providers, patient advocates and policy makers who are interested in improving the care for dementia patients in Indianapolis were invited to participate in bimonthly face-to-face meetings and regular email interactions. The Network uses the Complex Adaptive System theoretical framework and the Reflective Adaptive Process to facilitate and sustain effective interactions among its members. The Network was established in February 2006 and includes more than 150 members from more than 20 local organizations, representing over 20 disciplines. To date, the network has built a web-based resource center, created a social networking forum through Facebook, has delivered numerous educational seminars, developed and disseminated educational materials and quick reference cards; and developed numerous clinical tools. Currently, the Network is deploying research projects into community practices, looking at a new screening and management tool (the Healthy Aging Brain Care Monitor), has developed an electronic medical record specifically designed to address the concerns of the cognitively impaired population (eMR-ABC), and has taken a NIH funded study into primary care practices outside of academic practice setting (PRISM-PC). Building and sustaining a local interdisciplinary “think-tank” network in dementia facilitates conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.

Complexity science suggests that our current health care delivery system acts as a complex adaptive system (CAS). Such systems represent a dynamic and flexible network of individuals who can coevolve with their ever changing environment. The CAS performance fluctuates and its members' interactions continuously change over time in response to the stress generated by its surrounding environment. This paper will review the challenges of intervening and introducing a planned change into a complex adaptive health care delivery system. We explore the role of the reflective adaptive process in developing delivery interventions and suggest different evaluation methodologies to study the impact of such interventions on the performance of the entire system. We finally describe the implementation of a new program, the Aging Brain Care Medical Home as a case study of our proposed evaluation process.

BACKGROUND AND OBJECTIVES Despite the significant burden of delirium among hospitalized adults, there is no approved pharmacologic intervention for delirium. This systematic review evaluates the efficacy and safety of pharmacologic interventions targeting either prevention or management of delirium. DATA SOURCES We searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to October 2008. We included randomized, controlled trials comparing pharmacologic compounds either to each other or placebo. We excluded non-comparison trials, studies with patients aged < 18 years, a history of an Axis I psychiatric disorder, and patients with alcohol-related delirium. REVIEW METHODS Three reviewers independently extracted the data for participants, interventions and outcome measures, and critically appraised each study using the JADAD scale. RESULTS We identified 13 studies that met our inclusion criteria and evaluated 15 compounds: second-generation antipsychotics, first-generation antipsychotics, cholinergic enhancers, an antiepileptic agent, an inhaled anesthetic, injectable sedatives, and a benzodiazepine. Four trials evaluated delirium treatment and suggested no differences in efficacy or safety among the evaluated treatment methods (first and second generation antipsychotics). Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium. Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing elective or emergent surgical procedures. CONCLUSION The existing limited data indicates no superiority for second-generation antipsychotics over haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished through various mechanisms, further studies are necessary to prove effectiveness.

1Regenstrief Institute, Inc. Indianapolis, In, UsA; 2Indiana University Center for Aging Research; 3Department of Medicine, Indiana University school of Medicine, Indianapolis, In, UsA; 4Wishard health services, Indianapolis, In, UsA; 5school of Pharmacy and Pharmaceutical sciences, Purdue University, West Lafayette, In, UsA; 6Kent Institute of Medicine and health sciences, University of Kent, Canterbury, Kent, UK; 7Kent and Medway nhs Trust, Dartford, Kent, UK; 8Postgraduate Medical Institute, University of hull, hull, UK; 9Penn state University school of nursing; 10Department of Psychiatry, Penn state College of Medicine; 11Indiana University Medical group – Primary Care, Indianapolis, In, UsA

Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes.Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults.Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies.Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles.Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes.Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia.Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.

Objective: in an effort to enhance medication prescribing for older adults and reduce the burden of cognitive impairment, this paper reviews the literature regarding the negative impact of anticholinergics on cognitive function and provides clinicians with a practical guidance for anticholinergic use in older adults. Methods: a Medline search identified studies evaluating the use of anticholinergics and the relationship between anticholinergics and cognitive impairment. Results: prescribing anticholinergics for older adults leads to acute cognitive impairment and, possibly, chronic cognitive deficits. Assessing anticholinergic burden with a simple scale may represent a useful noninvasive tool to optimize geriatric pharmacotherapy. Conclusion: more studies are needed to validate the Anticholinergic Cognitive Burden scale and establish therapeutic guidelines in the presence of cognitive anticholinergic adverse effects.

Despite numerous quality improvement efforts, best practice guidelines, and clinical and basic research activities over the past three decades, dementia is still underdiagnosed and undertreated, especially among minorities. Furthermore, even among those receiving optimal care, only a small proportion participate in clinical trials. The Institute of Medicine has recommended the need for system thinking and integrated, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. It is hypothesized that an effective collaboration would improve diagnosis and treatment of the dementia patient, as well as increase participation in research. A local and diverse network of dementia researchers, clinical providers, and policy makers who are interested in improving the care for dementia patients in Indianapolis was invited to participate in bimonthly meetings. The Network uses the Complex Adaptive System theoretical framework and the Reflective Adaptive Process to facilitate and sustain effective interactions among its members. The Network was established in February 2006 and includes more than 60 members from more than 20 local organizations representing geriatrics, neurology, psychiatry, pathology, neuropsychology, psychology, nursing, social work, primary care, geriatric pharmacy, health services research, epidemiology, pharmaceutical industry, Alzheimer advocacy, state policy makers, health administration, medical education, and biostatistics. The network uses two types of communication among its members. The first is a 3-hour face-to-face bimonthly meeting that includes all members. The second is a project-based workgroup meeting that focuses on a specific task and includes a segment of the network members. To date, the network has built a web-based resource center, completed 4 full-day educational seminars, received funding to test a research enrollment process utilizing the local Alzheimer's Association help line, enabled clinicians to refer patients directly to a research registry, facilitated the submission of two NIH applications, tested a new group interaction method called “consultancy”, and has established a new dementia care clinic at the county hospital. Building a local interdisciplinary “think-tank” network in dementia facilitates conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.

Approximately 50% of hospitalized elders have cognitive impairment (CI) that increases their vulnerability to hospital-acquired complications. Matching geriatric evaluation and recommendations to the true pace of hospital care may improve the care of elders in general, in particular those with CI. Integrating information technology into geriatric services (gero-informatics) might allow reduction of the time to implementation of geriatric recommendations and prevent the initiation of potentially harmful medications and procedures during the critical first 48 hours of hospitalization. This paper reviews our local gero-informatics early experience of developing a computerized decision support system (CDSS) to enhance hospital care for elders with CI by reducing inappropriate use of anticholinergic medications, urinary catheters, and physical restraints.

Approximately 50% of hospitalized elders have cognitive impairment (CI) that may increase their vulnerability to hospital–acquired complications. Evidence suggests that the clinical benefits of inpatient interdisciplinary geriatrics services are limited. Reasons for such limitations may include the increasing complexity of medical decision–making and the ever–quickening pace of care in the hospital. Thus, matching geriatric evaluation and recommendations to the true pace of hospital care may be one mechanism to improve the care of elders in general and those with CI in particular. Integrating information technology into inpatient geriatric services might allow reduction of the time to implementation of geriatric recommendations with a specific focus on avoiding potentially harmful medications and procedures during the critical first 48 hours of hospitalization. To develop a computerized decision support system (CDSS) that will enhance hospital care for elders with CI via the reduction of inappropriate use of anticholinergic medications, urinary catheters, and physical restraints. We used the Complex Adaptive System model to integrate the content of relevant national guidelines with the expertise of local opinion leaders, and to improve the flexibility of CDSS to respond to changes in the local system. We have successfully assembled a team of local experts and finalized the content and format of the CDSS. The experts include geriatricians, hospitalists, physicians–in–training, pharmacists, nurses and computer programmers. The expert panel has created a dialogue to alert physicians of a patient's CI by way of the computerized order entry system. The panel has also developed a list of centrally acting anticholinergic drugs that may be harmful to patients with CI. An academic detailing program was developed to inform staff, interns, residents, and medical students of the study, providing them with information sessions on delirium and CI, and allowing them opportunities to present feedback about the study design and implementation. Using a complex adaptive system as a model might help to prepare a local hospital system to adapt a computerized decision support tool to improve the care of elders with CI.

Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition. Clinical scenario A 78-year-old Caucasian female presents to the emergency department (ED) with a chief complaint of shortness of breath, lethargy, and confusion. She was transported to the ED by her neighbor who assists with the history due to the patient's current state of confusion. The patient lives alone in her own apartment in an independent senior living facility and has noted a decreased ability to complete her daily activities due to her shortness of breath and fatigue. Her past medical history is positive for hypertension, urinary incontinence, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and atrial fibrillation. Her home medications include: ranitidine 150 mg by mouth twice daily, atenolol 50 mg by mouth daily, ipratropium inhaler 1–2 inhalations by mouth four times daily as needed, digoxin 0.125 mg by mouth daily, warfarin 3 mg by mouth daily, calcium carbonate/vitamin D 500 mg/200 IU by mouth twice daily, and Tyelonol PM ® 500 mg/25 mg by mouth as needed for sleep. She is admitted for Dovepress chronic obstructive pulmonary disease (COPD) exacerbation and to rule out myocardial infarction. Her cognitive testing on admission reveals a Mini-Mental Status Examination (MMSE) score of 19/30 with deficits in orientation, attention, and recall. She scores positive on a Confusion Assessment Method (CAM) evaluation due to an acute change in mental status, disorganized thinking, …

Complexity science suggests that our current health care delivery system acts as a complex adaptive system (CAS). Such systems represent a dynamic and flexible network of individuals who can coevolve with their ever changing environment. The CAS performance fluctuates and its members' interactions continuously change over time in response to the stress generated by its surrounding environment. This paper will review the challenges of intervening and introducing a planned change into a complex adaptive health care delivery system. We explore the role of the " reflective adaptive process " in developing delivery interventions and suggest different evaluation methodologies to study the impact of such interventions on the performance of the entire system. We finally describe the implementation of a new program, the Aging Brain Care Medical Home as a case study of our proposed evaluation process.